title: Paradoxical trends and racial differences in obstetric quality and neonatal and maternal mortality.
abstract: OBJECTIVE
  To evaluate trends by race in Agency for Healthcare Research and Quality obstetric-related quality and safety indicators and their relationships to trends in inpatient maternal and neonatal mortality.
  
  
  METHODS
  We used the Nationwide Inpatient Sample from 2000 through 2009 and calculated obstetric hospital quality and patient safety indicators and inpatient maternal and neonatal mortality stratified by race. We examined differences in age and comorbidity-adjusted trends in black compared with white women over time in the United States and by geographic region. Proportions were analyzed by χ2 and trends by regression analysis.
  
  
  RESULTS
  Obstetric quality indicators varied by geographic region, but changes over time were consistent for both races. Cesarean deliveries increased similarly for black and white women, and vaginal births after cesarean delivery declined for both races but more rapidly for white women than for black women. Obstetric safety indicators improved over the study period for black and white women, with obstetric trauma decreasing significantly for both groups (28% compared with 35%, respectively) and birth trauma-injury to neonates declining for both, but changes were not significant. In striking contrast, inpatient maternal and neonatal mortality remained relatively constant during the study period, with persistently higher rates of both seen among black compared with white women (12.0 compared with 4.6 per 100,000 deliveries, P<.001 and 6.6 compared with 2.5 per 1,000 births, P<.001, respectively, in 2009).
  
  
  CONCLUSIONS
  Improvements in Agency for Healthcare Research and Quality quality indicators for obstetrics are not reflected in improvements in maternal and neonatal morbidity and mortality and do not explain continued racial disparities for outcomes in pregnancies in black and white women. Quality measures that are related to pregnancy outcomes are needed and these should elucidate obstetric health disparities.
authors.affiliation: Departments of Health Evidence & Policy, Obstetrics, Gynecology, and Reproductive Science, and Psychiatry, Mount Sinai School of Medicine, New York, New York; the Epidemiological Research Unit on Perinatal Health and Women's and Children's Health, UMRS 953, INSERM Paris, France; and the Department of Health Services, University of Washington School of Public Health, Seattle, Washington.
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Howell
authors.forename: Jennifer
authors.initials: J
authors.lastname: Zeitlin
authors.forename: Paul
authors.initials: P
authors.lastname: Hebert
authors.forename: Amy
authors.initials: A
authors.lastname: Balbierz
authors.forename: Natalia
authors.initials: N
authors.lastname: Egorova
mesh_terms: D001741:Black or African American / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D007226:Infant Mortality / Q000208:ethnology* / Q000639:trends; D007231:Infant, Newborn; D008428:Maternal Mortality / Q000208:ethnology* / Q000639:trends; D009774:Obstetrics / Q000706:statistics & numerical data / Q000639:trends; D061214:Patient Safety / Q000706:statistics & numerical data; D011247:Pregnancy; D019984:Quality Indicators, Health Care / Q000706:statistics & numerical data / Q000639:trends; D014481:United States / Q000453:epidemiology; D044465:White People / Q000706:statistics & numerical data